Psoriasis in Women

Generally speaking, the incidence, prevalence, and manifestation of psoriasis of the skin are similar between the sexes, but the burden of psoriasis is somewhat heavier for women than men, and there are some sex-dependent differences in disease manifestation, severity, subjective disease perception, and treatment choices.

"Overall, women have lower disease severity, as measured by the Psoriasis Area Severity Index, but they experience higher impairment of their quality of life, as measured by the Dermatology Life Quality Index," said Chris G. Adigun, MD, of the Dermatology & Laser Center of Chapel Hill, North Carolina. "Women with psoriasis also have higher rates of depression compared to men."

However, Sonya Kenkare, MD, of the Illinois Dermatology Institute in Hinsdale, said that she "commonly see[s] depression in both sexes."

As for sex-specific lesion sites, "scalp psoriasis is more common in women, but men can get it there, too," Kenkare added. "In terms of age, there can be a peak in psoriasis frequency at puberty and a small peak at menopause."

In terms of treatment, data suggest women respond better to systemic therapy than men, but they also experience more adverse events related to treatment, said Adigun.

Female Hormones, Pregnancy

Hormones set off immune changes in the skin, and psoriasis symptoms can flare during puberty, after childbirth, and at menopause. Because this widespread dermatitis affects women in their reproductive years, female patients need special attention and more nuanced treatment.

The usual hormonal fluctuations of the monthly menstrual cycle do not have much impact, said Kenkare, but the high hormonal levels of pregnancy can correlate with symptom improvement. "I generally see improvement in about a third of pregnant women, but the condition quickly returns to pre-delivery status after delivery," she said.

"It is estimated that 30% to 40% of women have improvement in their psoriasis during pregnancy, with brisk worsening of their disease at 4 to 6 weeks postpartum," Adigun said. "And 40% to 90% of women experience a flare in their psoriasis in this immediate postpartum period."

One recent review reported that about 50% of women improve during gestation, while 25% worsen and 25% have no change.

There seems to be a correlation between high estrogen levels and improvements, which is supported by estrogen's dual effect: it can have both immunosuppressive and immunostimulatory functions. Gestational improvement may also be due in part to immune system alterations that occur to prevent rejection of the fetus.

According to one study, proinflammatory T helper (Th)-1 cytokines are upregulated in psoriasis and play a key role in the inflammatory cascades. "It is likely that during pregnancy the Th-2 cytokine-mediated downregulation of the immune response by virtue of its anti-inflammatory and antagonizing effects on the Th-1 cytokines improves psoriasis," these study authors wrote.

The effect on psoriasis of hormonal injections for pre-in vitro fertilization (IVF) egg stimulation and retrieval in IVF treatment has not really been studied, Kenkare said.

Since studies are few and results are mixed, there is no convincing evidence that psoriasis impairs fertility in either sex, according to Tina Bhutani, MD, MAS, of the Psoriasis and Skin Treatment Center at the University of California San Francisco. But based on proxy subfertility data from other systemic inflammatory diseases such as rheumatoid arthritis, "there may be an inflammatory effect that perhaps makes it harder for some to conceive," she said.

Most women with psoriasis can readily get pregnant, added Kenkare. "But there may be an indirect correlation with reduced fertility through comorbidities. Psoriasis is associated with metabolic syndrome, obesity, and type 2 diabetes, and these can be associated with ovarian suppression," she said.

Because some psoriasis treatments are teratogenic, therapy must be carefully managed in the pre-conception, pregnancy, and lactation stages, but treatment should continue -- especially for severe psoriasis. "There could be bad outcomes in the case of uncontrolled disease, although again the study results are mixed," said Bhutani.

Kenkare added that she "reassure[s] women that even if they are pregnant or nursing, we can still treat their psoriasis and we should." Options for safe treatment during pregnancy or lactation are limited, however, owing to lack of safety data for the developing fetus or secretion into breast milk.

Fortunately, there are safe therapies for pregnant women, including steroids, biologics, topicals, and photo therapy, and also a few that should categorically be avoided such as birth defect-linked retinol and isotretinoin. "Undertreating severe disease can negatively impact the pregnancy, so we need to evaluate what's happening in an individual very carefully," Kenkare said.

She recommended a consultation with a dermatologist for affected women who are pregnant or planning to be. "I've never known a woman with psoriasis who decided not to get pregnant because of her condition. Usually we can figure something out, but treatment during pregnancy is more complex and needs to be really nuanced."

Adigun noted that, "typically, topical therapies during pregnancy and/or lactation are limited to topical steroids, and systemic therapies to the tumor necrosis factor (TNF)-alpha inhibitors."

As for pregnancy outcomes, does the inflammatory milieu bode ill for maternal and fetal events? "Adverse events do not differ much from those in the general pregnant population, but there may be a trend in that direction, so we recommend that psoriasis patients see a dermatologist in conjunction with their obstetrician to make sure their inflammation is kept under control," said Bhutani.

A 2023 Iranian meta-analysis showed modest but significant associations between psoriasis and maternal outcomes, including cesarean delivery, pre-eclampsia/eclampsia, gestational diabetes and hypertension, and preterm birth. A significant association was also observed for adverse neonatal outcomes, including small for gestational age, low birth weight, and stillbirth.

In a large Danish case-control study, there was a 2.48% higher absolute risk of ectopic pregnancy for women with moderate-to-severe psoriasis compared with unaffected women, but no other adverse outcomes. In addition, a large British cohort study found slightly higher fertility rates in psoriasis-affected women versus unaffected women generally, but slightly lower rates in those with moderate to severe disease, as well as a slightly higher risk of pregnancy loss in all women with psoriasis, which was perhaps related to comorbidities.

Though mixed, such findings call for greater emphasis on managing comorbidities as part of routine obstetrical care. Also warranted is more research on the underlying causes of adverse pregnancy outcomes in affected women. All experts agree that the care of pregnant women with psoriasis should involve consultation with a dermatologist.

Comment